Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you approach treatment of a glioblastoma in pregnancy?
Glioblastoma during pregnancy could be treated safely (to mother and fetus) with certain precautions and modifications. Collaboration and consultation with the patient’s obstetrician are essential. External shielding over the patient’s abdomen during treatment will decrease the external scatter radi...
What is your approach to the diagnostic workup of small fiber neuropathy in patients with known rheumatic disease?
Small fiber sensory neuropathy (SFN), in general, including in patients with rheumatic diseases, should be suspected based on symptoms (positive more than negative sensory symptoms) and ideally confirmed by clinical examination showing altered temperature and/or pain/pinprick perception in the limbs...
When would you escalate moderate efficacy therapy for MS in a clinically stable patient with a single new clinically silent MRI lesion?
Sure. What is 'moderate efficacy therapy'? How is that defined? And who defines that? Refs? Secondly, a new lesion implies BBB breakdown (supposedly, if it is a T1 gad-enhancing lesion) and so, I would change therapy. My slant is always to use the best data available, so I would use the most efficac...
How do you navigate conversations with patients who are reluctant to start high-efficacy DMTs due to infection risk?
I usually frame the discussion around the balance between the risk of infection and the risk of undertreating MS. In younger patients with relapsing MS, particularly those with active disease or other features associated with a higher risk of future disability, I favor early use of high-efficacy the...
What do you do for a patient with Parkinson's Disease and orthostatic hypotension who has failed midodrine, fludrocortisone, droxidopa, pyridostigmine, and atomoxetine?
I would not recommend using amantadine in this situation as it is known to worsen orthostatic hypotension (Perez-Lloret et al., PMID 22336566). This is a tricky situation, and if the patient has failed all of these medications, I would consider an alternate diagnosis, specifically MSA, especially if...
Which calculators, nomograms, or other resources, if any, do you use to help advise and prognosticate patients with newly diagnosed glioblastoma or other gliomas?
This is a rather difficult question to answer because prognosis in patients with glioblastoma (GBM) is best estimated by combining several clinical, molecular, radiographic, and treatment-related factors rather than relying on any single variable. Several validated prognostic models exist, but in cl...
When would you consider using occipital nerve blocks to treat episodic cluster headaches?
For many years, it has been known that occipital nerve blocks containing steroids help for a few days in episodic cluster headache. But giving steroids by mouth for 3-5 days also works well and lasts for several days (for migraine attacks, I prefer occipital nerve blocks with local anesthesia and no...
What treatments options may be considered in patients with POTS who also need daily diuretics to treat heart failure and are already wearing compression garments?
Given the epidemiology of POTS and congestive heart failure, you are far more likely to see a patient with neurogenic orthostatic hypotension and CHF than POTS and CHF. I have an article on NOH and CHF in Autonomic Neuroscience 2020. The principals are basically the same however because the managem...
Under what circumstances do you decide to place an EVD for patients with cerbellar ischemic stroke?
Although placement of an EVD in a patient with cerebellar infarction can be lifesaving, I rarely use it as a sole treatment for that condition due to the risk of upward herniation. Typically, when the cerebellar infarction has created enough mass effect to cause hydrocephalus, the patient also requi...
When do you consider pacing in arrhythmogenic epilepsy?
I have seen only rare cases of it. They all had tonic-clonic seizures triggered by profound bradycardia (sinus as well as AV block). In turn, the bradyarrhythmia was triggered by EEG-documented temporal lobe absence seizures. They all resolved long-term with pacing. Regardless of the un...